A nurse enters a client's room and finds the client experiencing a seizure on the floor. Which of the following actions should the nurse take?
Place a pillow under the client's head.
Gently restrain the client's arms.
Administer a muscle relaxant.
Insert a tongue blade.
The Correct Answer is A
A. Place a pillow under the client's head. Placing a pillow under the client's head is appropriate as it helps protect the client's head from injury during the seizure. Providing cushioning can reduce the risk of head trauma, which is a common concern during seizures.
B. Gently restrain the client's arms. Gently restraining the client's arms is not recommended during a seizure, as it can lead to injury. Restraining movements can also increase the risk of injury to both the client and the caregiver. Instead, the nurse should allow the seizure to progress without interference.
C. Administer a muscle relaxant. Administering a muscle relaxant is not appropriate during a seizure. The nurse should not medicate the client until the seizure has stopped and the healthcare provider has assessed the situation. Immediate management focuses on safety rather than medication.
D. Insert a tongue blade. Inserting a tongue blade or any object into the client's mouth is dangerous and not recommended. This can cause oral injury, broken teeth, or airway obstruction. The nurse should ensure the area is clear of hazards and allow the seizure to occur without attempting to prevent movements.
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Related Questions
Correct Answer is C
Explanation
A. Time. The prescription states that erythromycin should be administered four times per day, which is a standard frequency for this medication. No clarification is needed unless there are specific timing concerns, such as administration with or without food.
B. Medication. Erythromycin is a commonly prescribed macrolide antibiotic used for bacterial infections. Since the medication itself is clearly stated, there is no need to clarify this aspect of the prescription.
C. Route. The prescription does not specify the route of administration (e.g., oral, intravenous, or topical). Since erythromycin is available in multiple forms, including oral tablets, capsules, liquid suspension, and intravenous formulations, it is essential to clarify the intended route with the provider before administration.
D. Dosage. A dose of 500 mg four times per day is a typical dosage for erythromycin in treating infections. Unless there are concerns regarding the client’s renal or hepatic function or potential drug interactions, the dosage does not require clarification.
Correct Answer is B
Explanation
A. Discontinue this medication if this occurs again. Stopping a newly prescribed medication without consulting a provider is not recommended. Many medications, including antihypertensives, can cause lightheadedness, and adjustments or precautions should be discussed with a healthcare provider rather than discontinuing the drug independently.
B. Sit back down for a few minutes when this occurs. Lightheadedness upon standing is often due to orthostatic hypotension, which can be managed by sitting back down to allow blood pressure to stabilize. Slowly changing positions, staying hydrated, and rising gradually can also help minimize symptoms.
C. Restrict your daily fluid intake. Reducing fluid intake can worsen symptoms of orthostatic hypotension by decreasing blood volume, leading to further drops in blood pressure. Instead, maintaining adequate hydration is essential to support circulatory stability and prevent dizziness.
D. Take a daily potassium supplement. Unless there is a confirmed potassium deficiency, supplementation is unnecessary and could lead to hyperkalemia, especially if the client is on medications affecting potassium levels. Lightheadedness is more commonly related to blood pressure changes rather than potassium imbalances.
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